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Assessment of Measurement Properties of Clinical Tests for Foot Posture in Children and Adolescents: A Systematic Review

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Title: Assessment of Measurement Properties of Clinical Tests for Foot Posture in Children and Adolescents: A Systematic Review
Language: English
Authors: Vanessa Gonçalves Coutinho de Oliveira (ORCID 0000-0002-3074-5316), Letícia Colombo de Oliveira (ORCID 0009-0003-7041-6503), Bruna Reclusa Martinez (ORCID 0000-0002-5746-2527), Thiago Melo Malheiros de Souza (ORCID 0000-0003-3382-4041), Nelson Carvas Junior (ORCID 0000-0003-2168-8927), Liu Chiao Yi (ORCID 0000-0003-0202-2337)
Source: Measurement in Physical Education and Exercise Science. 2025 29(3):282-293.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 12
Publication Date: 2025
Document Type: Journal Articles
Information Analyses
Reports - Research
Descriptors: Human Body, Human Posture, Children, Adolescents, Test Validity, Test Reliability, Physical Disabilities, Measurement
DOI: 10.1080/1091367X.2025.2457139
ISSN: 1091-367X
1532-7841
Abstract: The study aimed to analyze, synthesize, and investigate the measurement properties of clinical tests that assess foot posture in children and adolescents. The study included research published in scientific journals that analyzed the measurement properties of clinical tests, focusing on the validity, reliability, responsiveness, or specificity of tests for assessing foot posture in children and adolescents (ages 4 to 18 years). Studies involving children with lower limb surgery, neurological issues, or deformities, reviews, case studies, and abstracts were excluded. The search followed PRISMA guidelines on MEDLINE, EMBASE, PUBMED, CINAHL, SPORTDIscus. The methodological quality was assessed using the COSMIN and Brink and Louw tool, while the certainty of the evidence was evaluated using GRADE. Twelve studies were included in this systematic review, evaluating the following clinical tests: foot posture index-6, normalized truncated navicular height, Staheli index, plantar arch index, arch height index, navicular drop, resting and neutral calcaneal stance position, pediatric flat foot proforma, subjective perception of the height of the feet arch and Clarke angle. Current clinical tests predominantly prioritize the examination of intra- and inter-rater reliability. Conversely, validity has only been found in restricted studies, and responsiveness has not been assessed. No evidence supports high-quality measurement properties for clinical tests evaluating foot posture in children and adolescents.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1477720
Database: ERIC
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  Value: <anid>AN0186774326;7mm01jul.25;2025Jul23.02:56;v2.2.500</anid> <title id="AN0186774326-1">Assessment of Measurement Properties of Clinical Tests for Foot Posture in Children and Adolescents: A Systematic Review </title> <p>The study aimed to analyze, synthesize, and investigate the measurement properties of clinical tests that assess foot posture in children and adolescents. The study included research published in scientific journals that analyzed the measurement properties of clinical tests, focusing on the validity, reliability, responsiveness, or specificity of tests for assessing foot posture in children and adolescents (ages 4 to 18 years). Studies involving children with lower limb surgery, neurological issues, or deformities, reviews, case studies, and abstracts were excluded. The search followed PRISMA guidelines on MEDLINE, EMBASE, PUBMED, CINAHL, SPORTDIscus. The methodological quality was assessed using the COSMIN and Brink and Louw tool, while the certainty of the evidence was evaluated using GRADE. Twelve studies were included in this systematic review, evaluating the following clinical tests: foot posture index-6, normalized truncated navicular height, Staheli index, plantar arch index, arch height index, navicular drop, resting and neutral calcaneal stance position, pediatric flat foot proforma, subjective perception of the height of the feet arch and Clarke angle. Current clinical tests predominantly prioritize the examination of intra- and inter-rater reliability. Conversely, validity has only been found in restricted studies, and responsiveness has not been assessed. No evidence supports high-quality measurement properties for clinical tests evaluating foot posture in children and adolescents.</p> <p>Keywords: Child; adolescent; flat foot; foot posture; measurement properties</p> <hd id="AN0186774326-2">INTRODUTION</hd> <p>The human foot is a complex segment with 28 bones, 33 joints, and 20 muscles that allow locomotion, attenuate impact, and adapt the foot to different surfaces (McKeon et al., [<reflink idref="bib28" id="ref1">28</reflink>]). Evolutive evidence shows that the architecture and musculature of the foot arch were developed in response to the impact and increase in locomotion speed (McKeon et al., [<reflink idref="bib28" id="ref2">28</reflink>]). Thus, the current anatomic model was adapted (i.e., development of the longitudinal, medial, lateral, and transverse arches) to improve propulsion mechanics during walking, running, and functional tasks (Holowka et al., [<reflink idref="bib26" id="ref3">26</reflink>]).</p> <p>Foot postures are classified as neutral, cavus, or flat (when static) and supinated or pronated (when dynamic) and present biomechanical differences (e.g., plantar pressure, kinetic, and kinematic) during walking, running, and functional tasks (Buldt et al., [<reflink idref="bib7" id="ref4">7</reflink>], [<reflink idref="bib6" id="ref5">6</reflink>]; Hollander et al., [<reflink idref="bib25" id="ref6">25</reflink>]; Sanchis-Sales et al., [<reflink idref="bib38" id="ref7">38</reflink>]). According to foot characteristics, different injuries may also occur in adults (Neal et al., [<reflink idref="bib36" id="ref8">36</reflink>]). All typically developing children are born with flexible, flat feet. The development of the medial longitudinal arch occurs during the first decade of life, concurrent with the maturation of the bones, muscles, ligaments of the foot, and neuromuscular control (Banwell et al., [<reflink idref="bib3" id="ref9">3</reflink>]; Carr et al., [<reflink idref="bib8" id="ref10">8</reflink>]; Uden et al., [<reflink idref="bib42" id="ref11">42</reflink>]).</p> <p>The posture of children's feet is a common concern for parents, who often seek medical evaluation. The most frequent posture is the flat foot, with a prevalence of 15% after 10 years of age (Evans & Rome, [<reflink idref="bib19" id="ref12">19</reflink>]). Flatfoot in children and adolescents can be flexible, rigid, painful, or non-painful (Evans & Rome, [<reflink idref="bib19" id="ref13">19</reflink>]). Even though most childhood flatfoot cases are benign, some children may experience pain, foot and ankle, leg fatigue, limitations in daily activities, and calluses on the feet (Carr et al., [<reflink idref="bib8" id="ref14">8</reflink>]). The persistence of flatfoot may also be associated with a risk factor for lower limb injuries in adulthood (Carr et al., [<reflink idref="bib8" id="ref15">8</reflink>]). Pes cavus in childhood and adolescence is less frequent but often associated with underlying neurological diseases (Sanpera et al., [<reflink idref="bib39" id="ref16">39</reflink>]).</p> <p>The literature describes the classification of foot postures using image exams (radiographs), plantar pressure (capacitive and resistive insoles), a plantar impression (pedigraph), visual inspection, and clinical tests (Buldt et al., [<reflink idref="bib7" id="ref17">7</reflink>]; Carr et al., [<reflink idref="bib8" id="ref18">8</reflink>]; Hollander et al., [<reflink idref="bib25" id="ref19">25</reflink>]; Sanchis-Sales et al., [<reflink idref="bib38" id="ref20">38</reflink>]). Clinical tests, for example, are commonly performed using the navicular drop (Eichelberger et al., [<reflink idref="bib15" id="ref21">15</reflink>]), arch height index (Cavanagh & Rodgers, [<reflink idref="bib9" id="ref22">9</reflink>]), Clarke's angle (Gonzalez-Martin et al., [<reflink idref="bib21" id="ref23">21</reflink>]), rearfoot angle (Buck et al., [<reflink idref="bib5" id="ref24">5</reflink>]; Morrison & Ferrari, [<reflink idref="bib35" id="ref25">35</reflink>]), foot posture index-6 (Morrison & Ferrari, [<reflink idref="bib35" id="ref26">35</reflink>]), Staheli index (de Oliveira Beliche et al., [<reflink idref="bib11" id="ref27">11</reflink>]), navicular height (Evans, Copper, et al., [<reflink idref="bib17" id="ref28">17</reflink>]), resting and neutral calcaneal stance (Evans, Scutter, et al., [<reflink idref="bib20" id="ref29">20</reflink>]), and visual evaluation of foot photographs in medial and posterior views (angular and linear measurements) (Dimitrieva et al., [<reflink idref="bib13" id="ref30">13</reflink>]). The assessment of the medial longitudinal arch is frequently associated with foot structure, function, and injury risk in adulthood (Mootanah et al., [<reflink idref="bib34" id="ref31">34</reflink>]; Williams et al., [<reflink idref="bib43" id="ref32">43</reflink>]). Its height and mobility are considered the conditions that allow the modulation of lower limb rigidity and flexibility to attenuate loads and dissipate energy during foot-ground contact (Uden et al., [<reflink idref="bib42" id="ref33">42</reflink>]).</p> <p>Clinical tests to assess foot posture in children and adolescents are simple, quick, low-cost, and avoid unnecessary radiation exposure, such as that from X-rays, making them essential in clinical practice with children and adolescents. They may help professionals understand the current development of the medial longitudinal arch, guide the treatment, and determine the need and choice of intervention for the best foot posture evaluation (Uden et al., [<reflink idref="bib42" id="ref34">42</reflink>]). Therefore, validated, reliable, responsive clinical tests are essential (Mokkink et al., [<reflink idref="bib31" id="ref35">31</reflink>]). The literature needs more information regarding the best clinical test to assess foot posture in children and adolescents. It demonstrates that some measures may be biased toward a specific posture and lead to an early and wrong diagnosis (Banwell et al., [<reflink idref="bib3" id="ref36">3</reflink>]). A systematic review (Banwell et al., [<reflink idref="bib3" id="ref37">3</reflink>]) was conducted to compile the main studies addressing methods for assessing flatfoot in children. However, only studies in English were included in the search strategy, and the study's objective was not specific to the measurement properties of the tests.</p> <p>Considering the importance of selecting a clinical test with established measurement properties to assess foot posture, we conducted a systematic review to identify the clinical tests commonly used to classify foot posture, critically evaluate and synthesize the evidence, and investigate the most reliable, valid, and responsive clinical test capable of assessing the feet of children and adolescents.</p> <hd id="AN0186774326-3">Methods</hd> <p></p> <hd id="AN0186774326-4">Research question</hd> <p>The research question was formulated based on P (participant), E (exposure), and O (outcome). Participants were children and adolescents aged 4 to 18 of both sexes with symptomatic or asymptomatic feet. These volunteers were exposed to foot posture assessment using clinical tools. The evaluation of the measurement properties (validity, reliability, responsiveness, sensitivity, and specificity) of the tools used was considered (Moola et al., [<reflink idref="bib33" id="ref38">33</reflink>]).</p> <hd id="AN0186774326-5">Research protocol and registration</hd> <p>This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Supplemental Material 1). The study was registered at CRD42021244879 in the International Prospective Register of Systematic Reviews.</p> <hd id="AN0186774326-6">Search strategy</hd> <p>The search strategy was conducted without publication date or language using indexed terms, keywords, open-ended search terms, synonyms, and combinations of Boolean operators (Supplemental Material 2). Two assessors (LCO and LCY) independently analyzed the titles and abstracts of studies identified in five electronic databases: MEDLINE, EMBASE, PUBMED, CINAHL, SPORTDIscus. A manual search of the references of studies and Google Scholar was performed to identify peer-reviewed studies related to the topic. The systematic review's article search was carried out in the databases between July and August 2023.</p> <hd id="AN0186774326-7">Inclusion criteria</hd> <p></p> <ulist> <item> The samples included in the studies consisted of children and adolescents of both sexes, aged 4 to 18 years, and with symptomatic or asymptomatic feet</item> <p></p> <item> Complete studies published in scientific journals presented at least one measurement property (i.e., validity, reliability, responsivity, sensibility, and specificity) of clinical tests for assessing foot posture in children and adolescents.</item> <p></p> <item> The search was carried out without a year limit until August 2023, without language restriction.</item> </ulist> <hd id="AN0186774326-8">Exclusion criteria</hd> <p></p> <ulist> <item> Narrative and systematic reviews, case studies, commentaries, abstracts, and annals of congresses.</item> <p></p> <item> Studies including children and adolescents with lower limb surgery, history of central or peripheral neurological alterations, and congenital or acquired deformities.</item> <p></p> <item> Two assessors (LCO and LCY) independently conducted the database search, study selection, data extraction, and evaluation of methodological quality. A third assessor (TM) was not required, as there were no discrepancies between their assessments.</item> </ulist> <hd id="AN0186774326-9">Methodological quality</hd> <p>The methodological quality of studies was assessed using the Brink and Louw (Brink & Louw, [<reflink idref="bib4" id="ref39">4</reflink>]) tool for measurement properties, the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) (Mokkink et al., [<reflink idref="bib32" id="ref40">32</reflink>]), and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) (Guyatt et al., [<reflink idref="bib22" id="ref41">22</reflink>]).</p> <hd id="AN0186774326-10">Brink and Louw</hd> <p>The Brink and Louw tool assesses the methodological quality using 13 items (Brink & Louw, [<reflink idref="bib4" id="ref42">4</reflink>]). We converted the total number of "yes" answers into percentages relative to the combined total of "yes" and "no" answers. Answers categorized as "not applicable" were excluded from consideration. Methodological quality was categorized as follows: weak (<40%), moderate (40% to 59%), good (60% to 79%), and excellent (>80%). (Supplemental Material 4).</p> <hd id="AN0186774326-11">COSMIN</hd> <p>We employed the COSMIN framework, citing 14 evaluation criteria (Mokkink et al., [<reflink idref="bib31" id="ref43">31</reflink>]), to assess our study's methodological quality of measurement properties. Studies were categorized based on overall significance using worst-score classification. Scores were classified as excellent (<reflink idref="bib1" id="ref44">1</reflink>), good (<reflink idref="bib2" id="ref45">2</reflink>), regular (<reflink idref="bib3" id="ref46">3</reflink>), poor (<reflink idref="bib4" id="ref47">4</reflink>), or not applicable (Mokkink et al., [<reflink idref="bib31" id="ref48">31</reflink>]) (Supplemental Material 5).</p> <hd id="AN0186774326-12">Certainty of evidence</hd> <p>The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) assessed the certainty of evidence (i.e., the extent of our confidence that the effect estimates are correct). The GRADE system assumes that randomized clinical trials begin with a high certainty of evidence. In contrast, non-randomized observational and interventional studies begin with low certainty of evidence (Guyatt et al., [<reflink idref="bib22" id="ref49">22</reflink>]) due to a lack of randomization and confounding factors (Engels et al., [<reflink idref="bib16" id="ref50">16</reflink>]). Randomized controlled trials are assessed using five domains (risk of bias, inconsistency, indirectness of evidence, imprecision, and publication bias); in cases of non-adherence to the criterion, the certainty of evidence may be reduced by one or two levels. In observational studies, three additional domains are applied to increase the certainty of evidence: magnitude of the effect, dose-response, and plausible confounders (Engels et al., [<reflink idref="bib16" id="ref51">16</reflink>]) (Supplemental Material 6).</p> <hd id="AN0186774326-13">Best evidence synthesis</hd> <p>To classify the evidence levels of each test, we evaluate the quality of the measurement properties of two tests and classify them as "+ positive rating, - negative rating, ± conflicting rating? Indeterminate rating (<reflink idref="bib29" id="ref52">29</reflink>). This method of synthesizing evidence is similar to the method used to classify clinical trials. The possible levels of evidence are (<reflink idref="bib1" id="ref53">1</reflink>) strong, (<reflink idref="bib2" id="ref54">2</reflink>) moderate, (<reflink idref="bib3" id="ref55">3</reflink>) limited, (<reflink idref="bib4" id="ref56">4</reflink>) conflicting, and (<reflink idref="bib5" id="ref57">5</reflink>) unknown (Clark et al., [<reflink idref="bib10" id="ref58">10</reflink>]; Terwee et al., [<reflink idref="bib40" id="ref59">40</reflink>]) (Supplemental Material 7).</p> <hd id="AN0186774326-14">Results</hd> <p></p> <hd id="AN0186774326-15">Studies selection</hd> <p>The search strategy retrieved 6,457 studies from the following databases: MEDLINE, CENTRAL, EMBASE, CINAHL, PEDro, SPORTDiscus, and SciELO. Twelve additional studies were identified and manually added, bringing the total to 6,469. The selected studies were imported into the Rayyan® reference manager, where 377 duplicates were excluded. The peers conducted a manual review of these duplicates and confirmed their removal. After reading titles and abstracts, 16 studies were selected for full-text reading, and 12 were included in this review (Figure 1).</p> <p>Graph: Figure 1. Strategy search to identify included studies.</p> <hd id="AN0186774326-16">Data extraction</hd> <p>After data extraction, synthesis was performed and presented in a table (Table 1). Information was organized according to author names, publication date, study design, sample size, the mean age of children and adolescents, sex, study objective, clinical test performed, aim, description, and interpretation of the test, and measurement property assessed and its corresponding value.</p> <p>Table 1. Consolidated summary of data extraction from the articles.</p> <p> <ephtml> <table><thead><tr><td>Study</td><td>Type of the study</td><td>Sample characteristics</td><td>Test</td><td>Test description</td><td>Method purpose</td><td>Test scoring and interpretation</td></tr></thead><tbody><tr><td>Aboelnasr et al. (<xref ref-type="bibr" rid="bibr1">2019</xref>) <italic>(Egypt)</italic></td><td>Cross-Sectional Study</td><td>n = 300 Age 6–12 years (152 girls and 148 boys)</td><td>nor Normalized truncated navicular height (NTNH)</td><td>With the participant in a relaxed position, the medial prominence of the navicular tuberosity was palpated and marked with a pen. A ruler was used to measure the height of the navicular from the ground, defined as the perpendicular distance from the tuberosity of the navicular to the ground. The NTNH is obtained by dividing the NH by the truncated foot length.</td><td>To investigate the inter-examiner reliability, sensitivity, and specificity of NH in the assessment of foot posture in children using radiographic measurement as the gold standard.</td><td>A lower normalized navicular height ratio indicates a flatter foot.</td></tr><tr><td>Aboelnasr et al. (<xref ref-type="bibr" rid="bibr2">2018</xref>) <italic>(Egypt)</italic></td><td>Cross-Sectional Study</td><td>n = 612 Age 6–18 years</td><td>Normalized truncated navicular height</td><td>The most medial prominence of the navicular tuberosity was palpated and marked with an ink marker pen. A steel ruler measured the navicular height from the ground, defined as the perpendicular distance from the marked navicular tuberosity to the ground.</td><td>Investigate reliability and validity of NTNH in assessment of static foot posture to determine flatfoot in children and adolescents using radiographic measures as a criterion gold standard measure.</td><td /></tr><tr><td>de Oliveira Beliche et al. (<xref ref-type="bibr" rid="bibr11">2021</xref>) <italic>(Brazil)</italic></td><td>Cross-Sectional Study</td><td>n = 278 Age 6–10 years (133 girls and 145 boys)</td><td>Staheli Index</td><td>Foot images were captured with the child standing on the baropodometer. A line was drawn about the longitudinal arch of the forefoot and on the topography of the heel, and the plantar arch index was obtained by dividing the two lines.</td><td>To analyze intra- and inter-examiner reliability in the classification of children's longitudinal plantar arch.</td><td>Arc index values: Neutral (0.3 cm and 1.0 cm), flat (>1.0 cm), Tall (<0.3 cm)</td></tr><tr><td>Dimitrieva et al. (<xref ref-type="bibr" rid="bibr13">2020</xref>) <italic>(Russia)</italic></td><td>Longitudinal Study</td><td>n = 187 Age 7–11 years</td><td>Subjective perception of the height of the feet arch</td><td>The rater observes two photos of the foot, one in the posterior and one in the medial. He must choose one of three options: (1) plan, (2) not plan, (3) I have doubts.</td><td>To determine the consistency among orthopedists in the assessment of the plantar arch in visual diagnosis in pediatric patients.</td><td>Numerical coding of the experts' answers as follows: 1, "Yes, it is;" 2, "No, it is not;" 3, "Doubtful"</td></tr><tr><td>Drefus et al. (<xref ref-type="bibr" rid="bibr14">2017</xref>) <italic>(USA)</italic></td><td>Longitudinal Study</td><td>n = 30 Age 6–12 years (9 girls and 21 boys)</td><td>Arch height index (AHI)</td><td>Lower foot structure measurements for each subject: calcaneal stance position at rest (RCSP) and forefoot to back foot position (FF-RF). RCSP and FF-RF were measured with a 1◦ resolution goniometer.</td><td>To determine the intra and inter-rater reliability of the AHI in children.</td><td>3 types of feet: Plane: RCSP ≥ 4◦ valgus or FF-RF ≥ 4◦ varus; straight: 0◦ ≤ RCSP ≤ 2◦ valgus and 0◦ ≤ FF-RF ≤ 4◦ varus; or cavo: RCSP ≥ 0◦ varus and FF-RF ≥ 1◦ valgus"</td></tr><tr><td>Evans et al. (<xref ref-type="bibr" rid="bibr18">2009</xref>) <italic>(Australia)</italic></td><td>Cross-Sectional Study</td><td>n = 140 Age 7–10 years</td><td>Paediatric flat foot proforma (p-FFP)</td><td>The FFP offers a structured checklist approach to significant clinical findings, including arch shape, range of motion, tender areas, gait, and diagnostic studies.</td><td>Assess intra- and inter-rater/FFP meter reliability.</td><td>Highly pronated: 10 to 12, pronated: 6 to 9, neutral: 0 to 5, supinated: −1 to −4, highly supinated: −5 to −12</td></tr><tr><td>Evans, Copper, et al. (<xref ref-type="bibr" rid="bibr17">2003</xref>) <italic>(Australia)</italic></td><td>Longitudinal Study</td><td>n = 59 Age 4–6 years and 8–15 years (34 girls and 25 boys)</td><td>Foot posture index-6 (FPI-6)</td><td>Observation and palpation of structures: superolateral and inferolateral malleolar curvature, helbing sign, position of the frontal plane of the calcaneus, prominence in the region of the talonavicular joint, unity of the medial longitudinal arch, unity of the lateral edge of the foot and abduction and adduction of the forefoot in the hindfoot.</td><td>Assess intra- and inter-rater reliability.</td><td>FPI: normal (0 to 5); pronated (+6 to + 9); highly pronated (+10); supinated (−1 to −4); highly supinated (−5 to −12)</td></tr><tr><td /><td /><td /><td>Navicular Height</td><td>The medial portion of the foot was palpated to locate the navicular tuberosity and marked with a pen. The height of this mark from the ground was then measured and recorded. Measurements were taken with a millimeter ruler.</td><td /><td /></tr><tr><td /><td /><td /><td>Navicular Drop</td><td>Through medial palpation of the foot, the tuberosity of the navicular was located, and the location was marked with a pen. The examiner then placed the subject's foot in the neutral calcaneal position and asked the subject to maintain this position. The height of the foot mark about the ground was then measured and recorded (E1). The subject was then asked to relax the foot (calcaneal stance position at rest). The height of the foot mark above the ground was then measured and recorded.</td><td /><td>The navicular drop (ND) was then calculated as N1 - N2 = ND</td></tr><tr><td /><td /><td /><td>Resting calcaneal stance position</td><td>The calcaneus's medial and lateral bony edges were palpated and visually sectioned. The grade-increased tractograph was then used to measure the angle of the visualized calcaneal bisection line with the supporting surface. This was recorded as the resting position of the calcaneus.</td><td /><td /></tr><tr><td /><td /><td /><td>Neutral calcaneal stance position</td><td>The subject's subtalar joint was placed in a neutral position, approximated by palpating the head of the talus to verify congruence. The visualized calcaneal bisection was measured, as in the stance position of the calcaneus at rest and recorded as the stance position of the neutral calcaneus (in degrees).</td><td /><td /></tr><tr><td>Evans, Scutter, et al. (<xref ref-type="bibr" rid="bibr20">2003</xref>) <italic>(Australia)</italic></td><td>Cross-Sectional Study</td><td>n = 10 Age 4 years</td><td>Navicular height</td><td>Navicular height was measured with a steel ruler marked with millimeter increments. Subjects stood on their foot templates throughout the examinations to maintain a consistent foot position.</td><td>Assess the accuracy of the examiner's skin palpation of the navicular, which is required to validate the measure of navicular height.</td><td /></tr><tr><td>F. Hegazy et al. (<xref ref-type="bibr" rid="bibr24">2021</xref>) <italic>(United Arab Emirates)</italic></td><td>Cross-Sectional Study</td><td>n = 460 Age 12–18 years</td><td>FPI-6 and Clarke angle</td><td>This type of evaluation has six anatomical criteria, which are each graded from 0 (neutral) to + 1 or + 2 (pronated) and 1 or 2 (supinated): (1) Talar head palpation, in which the talus head is palpated in the front of the ankle in medial and lateral aspects; (2) supra and infra lateral malleolar curvature, which is seen at the back of the ankle region (3) calcaneal frontal plane position, where the orientation of the calcaneal tendon on the supporting surface is used as a reference. (4) talonavicular joint bulging (5) medial longitudinal arch height and congruence (6) forefoot abduction or adduction.</td><td>Evaluate and compare the validity and diagnostic accuracy of the FPI-6 and Clarke's Angle in determining adolescents' flexible flatfoot.</td><td>0 to + 5 is defined as usual, +6 to + 9 as pronated, +10 to + 12 as strongly pronated, −1 to − 4 as supinated, and − 5 to − 12 as strongly supinated foot</td></tr><tr><td>F. A. Hegazy et al. (<xref ref-type="bibr" rid="bibr23">2020</xref>) <italic>(United Arab Emirates and Egypit)</italic></td><td>Cross-Sectional Study</td><td>n = 612 Age 6–18 years (312 girls and 300 boys)</td><td>FPI-6</td><td>Scoring system that takes into account the three-dimensional nature of the foot.</td><td>Investigate the validity and accuracy of the diagnosis of FPI-6 using radiographic findings as the gold standard measure.</td><td>Highly pronated: 10 to 12, pronated: 6 to 9, neutral: 0 to 5, supinated: −1 to −4, highly supinated: −5 to −12</td></tr><tr><td>Morrison and Ferrari (<xref ref-type="bibr" rid="bibr35">2009</xref>) <italic>(United Kingdom)</italic></td><td>Longitudinal Study</td><td>n = 30 Age 5–16 years (16 girls and 14 boys)</td><td>FPI-6</td><td>Visual inspection of the foot in 3 dimensions.</td><td>Investigate the inter-rater reliability of the FPI-6 in pediatric foot assessment.</td><td>Highly pronated: 10 to 12, pronated: 6 to 9, neutral: 0 to 5, supinated: −1 to −4, highly supinated: −5 to −12</td></tr><tr><td>Pauk et al. (<xref ref-type="bibr" rid="bibr37">2014</xref>) <italic>(Poland)</italic></td><td>Cross-Sectional Study</td><td>n = 60 Age 9–16 years</td><td>Clarke angle</td><td>The Clarke angle was estimated using a podoscope (QMS-396) and manual photography. In summary, participants were asked to stand relaxed on a podoscope. In this position, the plantar region of the foot was measured with the load exerted on it.</td><td>Examine the validity and reliability of the Clarke angle as a practical method for quantification of foot posture in children.</td><td>Using the calculated Clarke angle, foot posture was classified as normal arch (Clarke angle, 42º to 48º) or flatfoot arch (Clarke angle, 42º).</td></tr></tbody></table> </ephtml> </p> <hd id="AN0186774326-17">Methodological quality</hd> <p>The methodological quality of studies was assessed using the Brink and Louw ([<reflink idref="bib4" id="ref60">4</reflink>]) tool for measurement properties and the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN)((Mokkink et al., [<reflink idref="bib31" id="ref61">31</reflink>]) for systematic reviews.</p> <hd id="AN0186774326-18">Brink and Louw</hd> <p>The primary limitations highlighted in the Brink and Louw tool refer mainly to items 4, 5, 6, and 7. These items address issues relating to intra- and inter-rater reliability assessment, rater blinding, and whether the evaluation period was enough to ensure that the target condition changed reasonably between the evaluations. Table 2 presents the consensus between assessors.</p> <p>Table 2. Critical appraisal of the measurement properties of the studies according to brink and Louw, and COSMIN reliability summary of the methodological quality of the measurement property.</p> <p> <ephtml> <table><thead><tr><td>Brink and Louw Tool</td><td>COSMIN</td></tr><tr><td>Study</td><td>Itens</td><td>% "YES"</td><td>Classification</td><td>Itens</td><td>Classification</td></tr><tr><td>1</td><td>2</td><td>3</td><td>4</td><td>5</td><td>6</td><td>7</td><td>8</td><td>9</td><td>10</td><td>11</td><td>12</td><td>13</td><td>1</td><td>2</td><td>3</td><td>4</td><td>5</td><td>6</td><td>7</td><td>8</td><td>9</td><td>10</td><td>11</td><td>12</td><td>13</td><td>14</td><td /></tr></thead><tbody><tr><td>Aboelnasr et al. (<xref ref-type="bibr" rid="bibr1">2019</xref>)</td><td>Y</td><td>N</td><td>Y</td><td>N/A</td><td>N</td><td>N/A</td><td>N</td><td>N</td><td>Y</td><td>Y</td><td>Y</td><td>N/A</td><td>Y</td><td>60%</td><td>Good</td><td>4</td><td>4</td><td>1</td><td>2</td><td>N/A</td><td>1</td><td>2</td><td>3</td><td>2</td><td>1</td><td>1</td><td>4</td><td>N/A</td><td>N/A</td><td>Poor</td></tr><tr><td>Aboelnasr et al. (<xref ref-type="bibr" rid="bibr2">2018</xref>)</td><td>Y</td><td>Y</td><td>Y</td><td>N</td><td>N</td><td>N</td><td>N</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>69,3%</td><td>Good</td><td>4</td><td>4</td><td>1</td><td>2</td><td>1</td><td>1</td><td>2</td><td>2</td><td>3</td><td>1</td><td>1</td><td>4</td><td>N/A</td><td>N/A</td><td>Poor</td></tr><tr><td>de Oliveira Beliche et al. (<xref ref-type="bibr" rid="bibr11">2021</xref>)</td><td>Y</td><td>Y</td><td>N/A</td><td>N</td><td>N</td><td>N</td><td>N/A</td><td>Y</td><td>N/A</td><td>Y</td><td>N/A</td><td>N/A</td><td>Y</td><td>62,50%</td><td>Good</td><td>4</td><td>4</td><td>1</td><td>2</td><td>4</td><td>1</td><td>1</td><td>3</td><td>1</td><td>1</td><td>1</td><td>1</td><td>1</td><td>N/A</td><td>Poor</td></tr><tr><td>Dimitrieva et al. (<xref ref-type="bibr" rid="bibr13">2020</xref>)</td><td>Y</td><td>Y</td><td>N/A</td><td>N</td><td>Y</td><td>Y</td><td>N/A</td><td>Y</td><td>N/A</td><td>Y</td><td>N/A</td><td>N</td><td>Y</td><td>66,60%</td><td>Good</td><td>4</td><td>4</td><td>2</td><td>2</td><td>4</td><td>1</td><td>2</td><td>3</td><td>1</td><td>1</td><td>2</td><td>4</td><td>N/A</td><td>N/A</td><td>Poor</td></tr><tr><td>Drefus et al. (<xref ref-type="bibr" rid="bibr14">2017</xref>)</td><td>Y</td><td>Y</td><td>N/A</td><td>N</td><td>N</td><td>N</td><td>N/A</td><td>Y</td><td>N/A</td><td>Y</td><td>N/A</td><td>N/A</td><td>Y</td><td>62,50%</td><td>Good</td><td>N/A</td><td>N/A</td><td>4</td><td>2</td><td>4</td><td>1</td><td>2</td><td>3</td><td>2</td><td>1</td><td>1</td><td>4</td><td>N/A</td><td>N/A</td><td>Poor</td></tr><tr><td>Evans et al. (<xref ref-type="bibr" rid="bibr18">2009</xref>)</td><td>N</td><td>N</td><td>N</td><td>N</td><td>N</td><td>N</td><td>N/A</td><td>Y</td><td>N/A</td><td>Y</td><td>N/A</td><td>N/A</td><td>Y</td><td>33,30%</td><td>Poor</td><td>N/A</td><td>N/A</td><td>3</td><td>2</td><td>1</td><td>1</td><td>1</td><td>3</td><td>2</td><td>1</td><td>2</td><td>4</td><td>N/A</td><td>N/A</td><td>Poor</td></tr><tr><td>Evans, Copper, et al. (<xref ref-type="bibr" rid="bibr17">2003</xref>)</td><td>Y</td><td>Y</td><td>N/A</td><td>Y</td><td>Y</td><td>Y</td><td>N/A</td><td>Y</td><td>N/A</td><td>Y</td><td>N/A</td><td>N/A</td><td>Y</td><td>100%</td><td>Excellent</td><td>N/A</td><td>N/A</td><td>4</td><td>2</td><td>4</td><td>4</td><td>2</td><td>4</td><td>3</td><td>1</td><td>1</td><td>4</td><td>N/A</td><td>N/A</td><td>Poor</td></tr><tr><td>Evans et al, 2002</td><td>N</td><td>Y</td><td>N/A</td><td>N/A</td><td>N</td><td>N</td><td>N/A</td><td>N</td><td>N/A</td><td>Y</td><td>N/A</td><td>Y</td><td>Y</td><td>50%</td><td>Moderate</td><td>N/A</td><td>N/A</td><td>2</td><td>4</td><td>4</td><td>1</td><td>2</td><td>3</td><td>1</td><td>1</td><td>1</td><td>4</td><td>N/A</td><td>N/A</td><td>Poor</td></tr><tr><td>F. Hegazy et al. (<xref ref-type="bibr" rid="bibr24">2021</xref>)</td><td>Y</td><td>Y</td><td>Y</td><td>N/A</td><td>Y</td><td>N</td><td>N</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>83,3%</td><td>Excellent</td><td>4</td><td>4</td><td>1</td><td>2</td><td>N/A</td><td>1</td><td>1</td><td>1</td><td>N/A</td><td>1</td><td>2</td><td>4</td><td>N/A</td><td>N/A</td><td>Poor</td></tr><tr><td>F. A. Hegazy et al. (<xref ref-type="bibr" rid="bibr23">2020</xref>)</td><td>Y</td><td>Y</td><td>Y</td><td>N/A</td><td>Y</td><td>N/A</td><td>N</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>90,90%</td><td>Excellent</td><td>N/A</td><td>N/A</td><td>1</td><td>2</td><td>4</td><td>1</td><td>2</td><td>2</td><td>3</td><td>1</td><td>1</td><td>4</td><td>N/A</td><td>N/A</td><td>Poor</td></tr><tr><td>Morrison and Ferrari (<xref ref-type="bibr" rid="bibr35">2009</xref>)</td><td>Y</td><td>Y</td><td>N/A</td><td>Y</td><td>N/A</td><td>Y</td><td>N/A</td><td>N</td><td>N/A</td><td>Y</td><td>N/A</td><td>N/A</td><td>Y</td><td>85,70%</td><td>Excellent</td><td>N/A</td><td>N/A</td><td>4</td><td>4</td><td>1</td><td>N/A</td><td>2</td><td>4</td><td>1</td><td>1</td><td>2</td><td>1</td><td>1</td><td>N/A</td><td>Poor</td></tr><tr><td>Pauk et al. (<xref ref-type="bibr" rid="bibr37">2014</xref>)</td><td>Y</td><td>N</td><td>Y</td><td>N/A</td><td>N</td><td>N</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>Y</td><td>75%</td><td>Moderate</td><td>4</td><td>4</td><td>1</td><td>2</td><td>1</td><td>2</td><td>2</td><td>3</td><td>1</td><td>1</td><td>1</td><td>4</td><td>N/A</td><td>N/A</td><td>Poor</td></tr></tbody></table> </ephtml> </p> <p>1 Y = "Yes," <emph>N</emph> = "No," N/A = not applicable. The table evaluates the following items: description of the sample used for the index test (Item 1), clarification of the rater(s) qualifications (Item 2), explanation of the reference standard (Item 3), blinding of raters in inter-rater reliability tests (Items 4–5), variation in the order of examination (Item 6), adequacy of time between reference standard and index test (Item 7), consideration of variable stability in the time interval between repeated measures (Item 8), independence of the reference standard from the index test (Item 9), sufficient detail for replicating the index test (Item 10) and reference standard (Item 11), explanation of withdrawals (Item 12), and appropriateness of statistical methods (Item 13). "Yes" is calculated based on applicable items with over 60% marked in bold. Adapted from Brink and Louw ([<reflink idref="bib4" id="ref62">4</reflink>]).</p> <p>2 COSMIN Grades: 1 = excellent, 2 = good, 3 = fair, 4 = poor, N/A = non-applicable. The table evaluates the following items: percentage of missing items (Item 1), handling of missing items (Item 2), adequacy of sample size (Item 3), availability of at least two measurements (Item 4), independence of administrations (Item 5), stated time interval (Item 6), patient stability regarding the construct (Item 7), appropriateness of time interval (Item 8), similarity of test conditions (Item 9), design or method flaws (Item 10), calculation of ICC for continuous scores (Item 11), calculation of kappa for dichotomous/nominal/ordinal scores (Item 12), weighted kappa for ordinal scores (Item 13), and description of weighting scheme for ordinal scores (Item 14). Methodological quality assessment was adapted from Mokkink et al. ([<reflink idref="bib32" id="ref63">32</reflink>]), Box B on reliability.</p> <hd id="AN0186774326-19">COSMIN</hd> <p>Our study used the COSMIN framework, referencing 14 evaluation criteria (Mokkink et al., [<reflink idref="bib31" id="ref64">31</reflink>]), to evaluate measurement property methodological quality. Studies were categorized based on overall significance using worst-score classification. Measurement property quality was assessed using scores ranging from excellent (<reflink idref="bib1" id="ref65">1</reflink>), good (<reflink idref="bib2" id="ref66">2</reflink>), regular (<reflink idref="bib3" id="ref67">3</reflink>), and poor (<reflink idref="bib4" id="ref68">4</reflink>) to not applicable (Mokkink et al., [<reflink idref="bib31" id="ref69">31</reflink>]).</p> <p>According to COSMIN, all studies were classified as poor methodological quality (Table 2).</p> <hd id="AN0186774326-20">Estimates of the effect</hd> <p>To identify the effect estimates of study reliability, data on intra-class correlation coefficients and 95% confidence intervals, or Kappa coefficients for intra- and inter-rater assessments, internal consistency (SEM and MDC – minimal detectable change), validity, specificity, and sensitivity were extracted (Supplemental Material 8).</p> <p>Studies showed heterogeneity regarding the types of feet assessed. Morrison and Ferrari ([<reflink idref="bib35" id="ref70">35</reflink>]) and Dimitrieva et al. ([<reflink idref="bib13" id="ref71">13</reflink>]) randomly selected the foot for analysis; F. A. Hegazy et al. ([<reflink idref="bib23" id="ref72">23</reflink>]) did not describe the analyzed foot; de Oliveira Beliche et al. ([<reflink idref="bib11" id="ref73">11</reflink>]) and Evans et al. ([<reflink idref="bib18" id="ref74">18</reflink>]) considered both feet for analysis; Drefus et al. ([<reflink idref="bib14" id="ref75">14</reflink>]) considered child and adolescents seated and standing but did not identify the feet; Evans, Copper, et al. ([<reflink idref="bib17" id="ref76">17</reflink>]) combined the total number of feet, duplicating the number of feet compared to sample size calculation; and Aboelnasr et al. ([<reflink idref="bib1" id="ref77">1</reflink>]) considered only the right foot. Studies assessed intra (de Oliveira Beliche et al., [<reflink idref="bib11" id="ref78">11</reflink>]; Dimitrieva et al., [<reflink idref="bib13" id="ref79">13</reflink>]; Drefus et al., [<reflink idref="bib14" id="ref80">14</reflink>]; Evans, Scutter, et al., [<reflink idref="bib20" id="ref81">20</reflink>]; F. A. Hegazy et al., [<reflink idref="bib24" id="ref82">24</reflink>], [<reflink idref="bib23" id="ref83">23</reflink>]; Pauk et al., [<reflink idref="bib37" id="ref84">37</reflink>]) and inter-rater (de Oliveira Beliche et al., [<reflink idref="bib11" id="ref85">11</reflink>]; Dimitrieva et al., [<reflink idref="bib13" id="ref86">13</reflink>]; Evans et al., [<reflink idref="bib18" id="ref87">18</reflink>]; Evans, Copper, et al., [<reflink idref="bib17" id="ref88">17</reflink>]; Morrison & Ferrari, [<reflink idref="bib35" id="ref89">35</reflink>]), reliability or both (de Oliveira Beliche et al., [<reflink idref="bib11" id="ref90">11</reflink>]; Dimitrieva et al., [<reflink idref="bib13" id="ref91">13</reflink>]; Drefus et al., [<reflink idref="bib14" id="ref92">14</reflink>]; Evans, Scutter, et al., [<reflink idref="bib20" id="ref93">20</reflink>]). F. A. Hegazy et al. ([<reflink idref="bib23" id="ref94">23</reflink>]), Aboelnasr et al. ([<reflink idref="bib1" id="ref95">1</reflink>]), and Pauk et al. ([<reflink idref="bib37" id="ref96">37</reflink>]) verified the validity. Radiographic findings were correlated with the foot posture index (F. A. Hegazy et al., [<reflink idref="bib23" id="ref97">23</reflink>]), Clarke angle (Pauk et al., [<reflink idref="bib37" id="ref98">37</reflink>]), and the normalized truncated navicular height test (Aboelnasr et al., [<reflink idref="bib1" id="ref99">1</reflink>]). No study assessed responsivity. A meta-analysis was not conducted due to the heterogeneity of studies included.</p> <hd id="AN0186774326-21">Certainty of evidence</hd> <p>The GRADE was assessed individually due to the heterogeneity of studies and the impossibility of conducting a meta-analysis. All articles included in the systematic review were classified by GRADE as Very Low, except Evans et al. ([<reflink idref="bib18" id="ref100">18</reflink>]), which were classified as Low (Supplemental Material 9).</p> <hd id="AN0186774326-22">Best evidence synthesis: levels of evidence</hd> <p>A summary of the best evidence for each of the 10 tests is provided in Table 3.</p> <p>Table 3. Levels of evidence for the measurement properties of clinical tests for foot posture in children and adolescents.</p> <p> <ephtml> <table><thead><tr><td>Test</td><td>Internal consistency</td><td>Reliability</td><td>Criterion Validity</td><td>Responsiveness</td></tr><tr><td>Intra-rater</td><td>Inter-rater</td></tr></thead><tbody><tr><td>foot posture index-6</td><td>No evidence</td><td>++ Moderate</td><td>++ Moderate</td><td>+ Limited</td><td>No evidence</td></tr><tr><td>Staheli Index</td><td>No evidence</td><td>+ Limited</td><td>+ Limited</td><td>No evidence</td><td>No evidence</td></tr><tr><td>normalized truncated navicular height</td><td>No evidence</td><td>? Conflicting evidence</td><td>++Moderate</td><td>+ Limited</td><td>No evidence</td></tr><tr><td>arch height index</td><td>No evidence</td><td>+ Limited</td><td>+ Limited</td><td>No evidence</td><td>No evidence</td></tr><tr><td>navicular drop</td><td>No evidence</td><td>? Conflicting evidence</td><td>− Limited</td><td>No evidence</td><td>No evidence</td></tr><tr><td>subjective perception of the height of the feet arch</td><td>Specialists +Limited/ Non specialists -Limited</td><td>No evidence</td><td>? Conflicting evidence</td><td>No evidence</td><td>No evidence</td></tr><tr><td>resting calcaneal stance position</td><td>No evidence</td><td>+ Limited</td><td>− Limited</td><td>No evidence</td><td>No evidence</td></tr><tr><td>neutral calcaneal stance position</td><td>No evidence</td><td>− Limited</td><td>− Limited</td><td>No evidence</td><td>No evidence</td></tr><tr><td>pediatric flat foot proforma (p-FFP)</td><td>No evidence</td><td>? Conflicting evidence</td><td>+ Limited</td><td>No evidence</td><td>No evidence</td></tr><tr><td>Clarke angle</td><td>No evidence</td><td>+ Limited</td><td>No evidence</td><td>+ Limited</td><td>No evidence</td></tr></tbody></table> </ephtml> </p> <p>3 +positive rating, - negative rating, ± conflicting rating,? indeterminate rating.</p> <hd id="AN0186774326-23">Discussion</hd> <p>This systematic review examined the measurement properties of clinical tests used to assess foot posture in children and adolescents, synthesizing findings across 12 studies. The reviewed tests included the Foot Posture Index-6 (FPI-6), normalized truncated navicular height, shell index, plantar arch index, arch height index, navicular drop, resting and neutral calcaneal stance position, Pediatric Flatfoot Proforma (p-FFP), subjective perception of the height of the foot arch, and Clarke angle (Aboelnasr et al., [<reflink idref="bib2" id="ref101">2</reflink>], [<reflink idref="bib1" id="ref102">1</reflink>]; de Oliveira Beliche et al., [<reflink idref="bib11" id="ref103">11</reflink>]; Dimitrieva et al., [<reflink idref="bib13" id="ref104">13</reflink>]; Drefus et al., [<reflink idref="bib14" id="ref105">14</reflink>]; Evans et al., [<reflink idref="bib17" id="ref106">17</reflink>], [<reflink idref="bib18" id="ref107">18</reflink>]; F. A. Hegazy et al., [<reflink idref="bib24" id="ref108">24</reflink>], [<reflink idref="bib23" id="ref109">23</reflink>]; Morrison & Ferrari, [<reflink idref="bib35" id="ref110">35</reflink>]; Pauk et al., [<reflink idref="bib37" id="ref111">37</reflink>]).</p> <p>Multiple classification tools were employed to evaluate the methodological quality of these studies, yielding varying results. Using the Brink and Louw tool (2012), studies were categorized as excellent (Evans, Scutter, et al., [<reflink idref="bib20" id="ref112">20</reflink>]; F. A. Hegazy et al., [<reflink idref="bib24" id="ref113">24</reflink>], [<reflink idref="bib23" id="ref114">23</reflink>]; Morrison & Ferrari, [<reflink idref="bib35" id="ref115">35</reflink>]), good (Aboelnasr et al., [<reflink idref="bib2" id="ref116">2</reflink>], [<reflink idref="bib1" id="ref117">1</reflink>]; de Oliveira Beliche et al., [<reflink idref="bib11" id="ref118">11</reflink>]; Dimitrieva et al., [<reflink idref="bib13" id="ref119">13</reflink>]; Drefus et al., [<reflink idref="bib14" id="ref120">14</reflink>]), moderate (Evans, Scutter, et al., [<reflink idref="bib20" id="ref121">20</reflink>]; Pauk et al., [<reflink idref="bib37" id="ref122">37</reflink>]), and poor (Evans et al., [<reflink idref="bib18" id="ref123">18</reflink>]). However, when evaluated using the COSMIN guidelines (Terwee et al., [<reflink idref="bib41" id="ref124">41</reflink>]), all studies were deemed to have poor methodological quality. The discrepancies were attributed primarily to sample size limitations (Clark et al., [<reflink idref="bib10" id="ref125">10</reflink>]) and methodological flaws overlooked by the Brink and Louw tool, such as incomplete reporting and handling of missing data. These issues, highlighted by COSMIN, can compromise statistical power and reduce precision and reliability (Kang, [<reflink idref="bib27" id="ref126">27</reflink>]).</p> <p>The GRADE approach (Guyatt et al., [<reflink idref="bib22" id="ref127">22</reflink>]) classified all studies as having low or very low certainty of evidence. Including exclusively observational studies and small sample sizes in seven of the studies likely contributed to this classification. Future research should emphasize larger sample sizes and improved methodological rigor to enhance statistical robustness.</p> <p>Among the tools evaluated, the Foot Posture Index-6 (FPI-6) emerged as the most frequently studied and clinically utilized measure for assessing foot posture in children and adolescents (Uden et al., [<reflink idref="bib42" id="ref128">42</reflink>]). Three studies assessed the FPI-6, reporting good to excellent intra-rater reliability and moderate to reasonable inter-rater reliability (Evans, Copper, et al., [<reflink idref="bib17" id="ref129">17</reflink>]; F. A. Hegazy et al., [<reflink idref="bib24" id="ref130">24</reflink>], [<reflink idref="bib23" id="ref131">23</reflink>]). Moreover, a single study (F. A. Hegazy et al., [<reflink idref="bib23" id="ref132">23</reflink>]) demonstrated excellent validity and high specificity and sensitivity, making the FPI-6 the most reliable and validated test in this review.</p> <p>Four studies evaluated the normalized truncated navicular height for intra-rater reliability (Aboelnasr et al., [<reflink idref="bib2" id="ref133">2</reflink>], [<reflink idref="bib1" id="ref134">1</reflink>]; Evans, Scutter, et al., [<reflink idref="bib20" id="ref135">20</reflink>]). While reliability was low in younger children aged 4–6, the test exhibited sensitivity and specificity for older children (6–12). Accurate results require normalization to foot length, as emphasized in these studies.</p> <p>Assessments of the medial longitudinal arch using plantar pressure measurements showed mixed results. The Staheli index (de Oliveira Beliche et al., [<reflink idref="bib11" id="ref136">11</reflink>]) demonstrated good inter-rater and excellent intra-rater reliability, whereas the Clarke angle (Pauk et al., [<reflink idref="bib37" id="ref137">37</reflink>]) achieved excellent intra-rater reliability but was categorized as low quality by COSMIN and GRADE. Both studies relied on samples with standard BMI despite evidence that elevated BMI may influence foot posture and arch height (Mickle et al., [<reflink idref="bib30" id="ref138">30</reflink>]).</p> <p>Other clinical tools, including the navicular drop, resting and neutral calcaneal stance positions, arch height index, and Pediatric Flatfoot Proforma, presented inconsistent findings. The arch height index (Drefus et al., [<reflink idref="bib14" id="ref139">14</reflink>]) showed limited evidence, with its utility further constrained by the requirement of a specialized measurement template. Similarly, while the Pediatric Flatfoot Proforma integrates well-validated clinical measures, it was rated as poor by both Brink and Louw ([<reflink idref="bib4" id="ref140">4</reflink>]) and COSMIN (Terwee et al., [<reflink idref="bib41" id="ref141">41</reflink>]).</p> <p>Reproducibility encompasses both concordance (measurement error) and reliability (the ability to distinguish between participants despite measurement error). Few studies assessed reproducibility metrics such as the standard error of the mean or the minimal detectable change. Only de Oliveira Beliche et al. ([<reflink idref="bib11" id="ref142">11</reflink>]), Evans, Copper, et al. ([<reflink idref="bib17" id="ref143">17</reflink>]), and Aboelnasr et al. ([<reflink idref="bib1" id="ref144">1</reflink>]) calculated the standard error of the mean, while minimal detectable change was addressed by these studies and Drefus et al. ([<reflink idref="bib14" id="ref145">14</reflink>]). The absence of these metrics limits interpretability and necessitates caution in test applications.</p> <p>Validity assessments were conducted for the FPI-6, Clarke angle, and normalized truncated navicular height, all of which demonstrated excellent validity, high specificity, and sensitivity (Aboelnasr et al., [<reflink idref="bib2" id="ref146">2</reflink>], [<reflink idref="bib1" id="ref147">1</reflink>]; F. A. Hegazy et al., [<reflink idref="bib24" id="ref148">24</reflink>], [<reflink idref="bib23" id="ref149">23</reflink>]; Pauk et al., [<reflink idref="bib37" id="ref150">37</reflink>]). However, the evidence synthesis categorized these tests as having limited evidence. Furthermore, none of the studies evaluated responsiveness – a critical property for detecting changes over time or post-intervention (De Vet et al., [<reflink idref="bib12" id="ref151">12</reflink>]).</p> <p>Heterogeneity in statistical analyses emerged as a key limitation. While some studies aggregated data from both feet, others analyzed each foot independently or randomized foot selection, introducing variability. Analyzing both feet together doubles the sample size and the variability of differences, increasing the likelihood of detecting significant differences (Menz, [<reflink idref="bib29" id="ref152">29</reflink>]). Despite the substantial research, this review highlights persistent methodological deficiencies, limited validity assessments, and the absence of responsiveness evaluations. These findings underscore the need for rigorous, methodologically robust studies to refine the clinical assessment of foot posture in pediatric populations.</p> <hd id="AN0186774326-24">Conclusion</hd> <p>Based on the results of this comprehensive review, there is no strong evidence supporting high-quality measurement properties for clinical tests assessing foot posture in children and adolescents. Moderate evidence is available solely for the reliability of the Foot Posture Index-6. Therefore, results from commonly used tests to evaluate foot posture in children and adolescents should be interpreted cautiously.</p> <hd id="AN0186774326-25">Disclosure statement</hd> <p>No potential conflict of interest was reported by the author(s).</p> <hd id="AN0186774326-26">Supplementary material</hd> <p>Supplemental data for this article can be accessed online at https://doi.org/10.1080/1091367X.2025.2457139</p> <ref id="AN0186774326-27"> <title> References </title> <blist> <bibl id="bib1" idref="ref44" type="bt">1</bibl> <bibtext> Aboelnasr, E. A., El-Talawy, H. A., Abdelazim, F. H., & Hegazy, F. A. (2019). Sensitivity and specificity of normalized truncated navicular height in assessment of static foot posture in children aged 6–12 years. 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  Data: <searchLink fieldCode="AR" term="%22Vanessa+Gonçalves+Coutinho+de+Oliveira%22">Vanessa Gonçalves Coutinho de Oliveira</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-3074-5316">0000-0002-3074-5316</externalLink>)<br /><searchLink fieldCode="AR" term="%22Letícia+Colombo+de+Oliveira%22">Letícia Colombo de Oliveira</searchLink> (ORCID <externalLink term="https://orcid.org/0009-0003-7041-6503">0009-0003-7041-6503</externalLink>)<br /><searchLink fieldCode="AR" term="%22Bruna+Reclusa+Martinez%22">Bruna Reclusa Martinez</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-5746-2527">0000-0002-5746-2527</externalLink>)<br /><searchLink fieldCode="AR" term="%22Thiago+Melo+Malheiros+de+Souza%22">Thiago Melo Malheiros de Souza</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-3382-4041">0000-0003-3382-4041</externalLink>)<br /><searchLink fieldCode="AR" term="%22Nelson+Carvas+Junior%22">Nelson Carvas Junior</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-2168-8927">0000-0003-2168-8927</externalLink>)<br /><searchLink fieldCode="AR" term="%22Liu+Chiao+Yi%22">Liu Chiao Yi</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-0202-2337">0000-0003-0202-2337</externalLink>)
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  Label: Descriptors
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  Data: <searchLink fieldCode="DE" term="%22Human+Body%22">Human Body</searchLink><br /><searchLink fieldCode="DE" term="%22Human+Posture%22">Human Posture</searchLink><br /><searchLink fieldCode="DE" term="%22Children%22">Children</searchLink><br /><searchLink fieldCode="DE" term="%22Adolescents%22">Adolescents</searchLink><br /><searchLink fieldCode="DE" term="%22Test+Validity%22">Test Validity</searchLink><br /><searchLink fieldCode="DE" term="%22Test+Reliability%22">Test Reliability</searchLink><br /><searchLink fieldCode="DE" term="%22Physical+Disabilities%22">Physical Disabilities</searchLink><br /><searchLink fieldCode="DE" term="%22Measurement%22">Measurement</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1080/1091367X.2025.2457139
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1091-367X<br />1532-7841
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: The study aimed to analyze, synthesize, and investigate the measurement properties of clinical tests that assess foot posture in children and adolescents. The study included research published in scientific journals that analyzed the measurement properties of clinical tests, focusing on the validity, reliability, responsiveness, or specificity of tests for assessing foot posture in children and adolescents (ages 4 to 18 years). Studies involving children with lower limb surgery, neurological issues, or deformities, reviews, case studies, and abstracts were excluded. The search followed PRISMA guidelines on MEDLINE, EMBASE, PUBMED, CINAHL, SPORTDIscus. The methodological quality was assessed using the COSMIN and Brink and Louw tool, while the certainty of the evidence was evaluated using GRADE. Twelve studies were included in this systematic review, evaluating the following clinical tests: foot posture index-6, normalized truncated navicular height, Staheli index, plantar arch index, arch height index, navicular drop, resting and neutral calcaneal stance position, pediatric flat foot proforma, subjective perception of the height of the feet arch and Clarke angle. Current clinical tests predominantly prioritize the examination of intra- and inter-rater reliability. Conversely, validity has only been found in restricted studies, and responsiveness has not been assessed. No evidence supports high-quality measurement properties for clinical tests evaluating foot posture in children and adolescents.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2025
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1477720
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1477720
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1080/1091367X.2025.2457139
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 12
        StartPage: 282
    Subjects:
      – SubjectFull: Human Body
        Type: general
      – SubjectFull: Human Posture
        Type: general
      – SubjectFull: Children
        Type: general
      – SubjectFull: Adolescents
        Type: general
      – SubjectFull: Test Validity
        Type: general
      – SubjectFull: Test Reliability
        Type: general
      – SubjectFull: Physical Disabilities
        Type: general
      – SubjectFull: Measurement
        Type: general
    Titles:
      – TitleFull: Assessment of Measurement Properties of Clinical Tests for Foot Posture in Children and Adolescents: A Systematic Review
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Vanessa Gonçalves Coutinho de Oliveira
      – PersonEntity:
          Name:
            NameFull: Letícia Colombo de Oliveira
      – PersonEntity:
          Name:
            NameFull: Bruna Reclusa Martinez
      – PersonEntity:
          Name:
            NameFull: Thiago Melo Malheiros de Souza
      – PersonEntity:
          Name:
            NameFull: Nelson Carvas Junior
      – PersonEntity:
          Name:
            NameFull: Liu Chiao Yi
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 01
              Type: published
              Y: 2025
          Identifiers:
            – Type: issn-print
              Value: 1091-367X
            – Type: issn-electronic
              Value: 1532-7841
          Numbering:
            – Type: volume
              Value: 29
            – Type: issue
              Value: 3
          Titles:
            – TitleFull: Measurement in Physical Education and Exercise Science
              Type: main
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